NHS Harrogate and Rural District Clinical Commissioning Group (the CCG) and Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) are developing a future vision for adult and older peoples mental health services.
We recognise the importance of good mental health services across the Harrogate area, and equally the support needed for carers.
We want to know what’s important to people, what has worked well, and what needs improving to make sure services are financially sustainable in the future and, most importantly, that they meet the needs of local people. This is a priority for us all.
We now have an opportunity and the ambition to do things differently - to look closely at the type of mental health care we need to provide in Harrogate.
People who use our mental health services tell us that whenever possible they want to remain at home, close to family and friends. This means making sure that support is available when they’re experiencing a crisis.
People also tell us we should work with them and their families to help them achieve the goals they’ve set themselves, making sure they get the care and treatment they need, when and where they need it.
Local public and patient involvement groups, voluntary organisations, mental health and social care professionals and the wider community have been having their say about how services can be further improved.
Our vision for the future
We want to work with local people and colleagues across health and social care to create a vision for mental health services which builds on good evidence and that provides the best outcomes for people. This includes:
- Empowering and supporting people to have more control over their lives
- Making sure people receive care in a trusted, respectful way and that they are able to develop hope inspiring relationships, where recovery and wellbeing come first.
- Making sure our services are easily accessible so that people can get the right level of support to help them stay well at home or as close to home as possible
Summary of feedback to date
Mental Health Strategies (MHS) were jointly commissioned by the Trust and the CCG to carry out some initial engagement. The findings of the listening and engagement exercise (July – October 2017) gave us a good insight into what local people are thinking.
MHS were able to group the findings into a number of key themes, which are outlined below.
Key themes from engagement to date
24/7 integrated and ‘joined up’ services
There was a general consensus from staff, service users and partner organisations that services felt disjointed and should be more ‘joined up’. People felt that different parts of the health and social care system should work more closely with each other, as well as with service users and their families. It was also clear that people felt community services should be more easily accessible and available in the evenings and at weekends.
Developing the workforce
We received some very positive comments about the commitment and passion of staff working in Harrogate. However, people also told us that we needed to nurture and invest in the development of the workforce.
Amongst other things, people said that more staff were needed, particularly in the community where staff felt burnt out. Some people also felt that there was a lack of knowledge and skills in some areas and that work was needed to improve attitudes and build a more compassionate workforce.
Service users described the service as needing to be more holistic in its approach. People said we should offer a greater range of support that would help individuals to help themselves to keep well (self- management) and to manage ‘blips’ or ‘setbacks’.
A number of people raised questions about the financial position and wanted to have a better understanding of what this means for services. Most people were aware and understood the need to make the most of the finite resources available to them although they also felt that services were not sufficiently resourced.
Improved pathways (clinical pathways are standard, evidenced-based assessment and treatment plans)
There was unanimous support for care being delivered as close to home as possible.
The needs of specific groups were discussed – for example the lack of dedicated pathways for people with complex, traumatic backgrounds (sometimes diagnosed with personality disorder). People welcomed the new focus on DBT training but felt that people were too busy to undertake the interventions and the need far outweighed the local investment to date.
The community mental health managers were concerned about the recent rate of change in service models and the new process for managing referrals and assessments. Community team managers largely welcomed the proposed community models, but were concerned about staffing levels and training.
Location of inpatient beds
People were disappointed that the development had been paused. However, there were mixed views about the future location of inpatient beds and some people felt that Cardale Park was not an ideal location (because it was isolated with limited transport links).
Some people felt that beds must remain in Harrogate for reasons of convenience, continuation of relationships and maintaining attachment with family, friends and neighbourhoods.
Others felt that moving beds from the immediate locality would not be detrimental. They said that people used to travel to York, and that access to more robust community services including alternatives to admission (crisis house or sanctuary out of hours service) would help those in crisis. Some people felt that having access to a high quality and specialist inpatient facility would outweigh the inconvenience of travelling.
For older adults, there was a stronger and more firmly asserted view expressed that travelling for older people was more difficult, and that wherever possible beds should be provided locally.
A number of people expressed the view that partnering with an independent provider, such as a nursing home, would be one solution. This might be the development of a wing of an existing facility to accommodate in-patient beds. For adults, this could be through partnering with independent providers already in Harrogate.
Some people suggested that having one specialist campus for the treatment and recovery of people in acute mental distress provides an opportunity to operate a larger inpatient facility, with highly specialist and skilled multi-disciplinary teams on one campus.
Alternatives to admission
Some practitioners were familiar with alternative models being used in Leeds and Bradford and were keen to bring these innovations to Harrogate. Service users were very interested in alternative non-medical models which supported greater self management and autonomy and which were in line with the Trust’s vision of implementing recovery.
A more preventative approach
People said that early access to services, as close to home as possible, was vital in preventing a crisis or a relapse. Some carers felt there were gaps in day care, day time support and respite care.
In general, people felt that partnership working in the Harrogate area was under-developed and that the third sector should be more visible and vibrant.
Improve patient and family outcomes – more recovery focus
The overwhelming response from participants was that the services in Harrogate and surrounding districts had a long way to travel on their journey to become recovery focused.
A strong message to come from the engagement process was that although they were disappointed with the decision to ‘pause’ the development of the new inpatient unit at Cardale Park, this was also a great opportunity to do something different, and perhaps radical.
For further discussion
There was overwhelming support for the further development of community services. In addition, based on feedback gathered to date, we have identified a number of different possibilities for the future development of mental health services for adults and older people in the Harrogate area:
- Retain adult mental health beds in Harrogate, or transfer to another site
- Retain older people’s mental health beds in Harrogate, or transfer to another site
- Develop a new form of dementia care in Harrogate
- Develop alternatives to acute mental health admission in Harrogate
What services do we currently provide?
Currently TEWV provides adult and older people’s inpatient and community services for people across Harrogate and Rural District.
Mental health inpatient services are provided from the Briary Wing at Harrogate District Hospital
Adult acute assessment and treatment inpatient services are provided from Cedar ward.
The 18-bed ward is mixed sex (with male and female zones) and consists of four dormitories (two male, two female) with access to five single rooms (one male, two female and two which can be used flexibly).
People are admitted to the ward when they are experiencing a crisis or acute mental health problem that can no longer be managed within a community setting.
Our aim is to provide high quality, patient-centred care with an emphasis on enhancing social inclusion and recovery in the least restrictive environment.
Therapeutic activities and group work contribute to individuals’ recovery, wellbeing and reintegration back home.
Older people’s acute assessment and treatment inpatient services are provided from Rowan ward.
The 16-bed ward is mixed sex (with male and female zones) and provides services for people with dementia (organic illnesses) as well as those with mental illnesses such as severe depression (functional illnesses).
The service aims to assess and treat people for six to eight weeks with a planned discharge to the patient’s own home or a long term placement which will meet the patient’s individual needs.
The service will assess, treat, manage and reduce difficult behaviours and risk and provide advice and training to relevant partners, professionals and agencies as part of the individual discharge plans. We strive to reduce risks to such a level that the individual can be discharged to their own home or to a care setting suitable for their current and long term needs.
A small number of patients whose needs cannot be met safely in this environment may need to be moved to an alternative, more specialist placement, such as Springwood.
We provide a range of general and specialist community mental health services for adults and older people across the Harrogate area:
- A crisis response and home intensive treatment team (available 24 hours a day, seven days a week) - supporting people aged 16 to 65 who need crisis support within 4hours and providing increased home treatment to help prevent admission to a mental health assessment and treatment ward. The crisis team also work with our local authority colleagues and police to support mental assessments in a health based place of safety (Section 136 suite).
- Two community teams across Harrogate and Ripon (available 9am – 5pm, Monday-Friday) - supporting people with moderate to severe need.
- Adult primary care team (available 9am – 5pm, Monday-Friday) who meet the needs of people with mild to moderate mental ill health
- Assertive outreach team (available 9am – 5pm, Monday-Friday) - supporting people with enduring mental illness.
- A community care service based in Knaresborough, (available 9am – 5pm, Monday-Friday)
- A rapid response team in the care of the elderly (RRICE) (available 8am – 6pm, seven days a week)
- A memory service providing assessment advice and support for people with memory problems and their families.
- An acute hospital liaison service which supports the acute hospital with assessment and care of older people with mental health difficulties who are admitted to acute hospitals for physical health conditions.
Currently most admissions to Rowan ward (older people) are made by the RRICE team.
The current pathway from community teams to inpatient units is being reviewed as part of the development of services in Harrogate.
In the future the process for admission for both adults and older people will be similar:
- referral to crisis team.
- crisis team to assess.
- decision made to admit or treat at home with home treatment intervention.
- admit for a fast track admission and review within 72 hours.
Demand for services
We are seeing a year on year increase in referrals to our older people’s services (from 2390 in 2014/15 to 3678 in 2016/17).
Referrals to our adult services have reduced over the last three years (from 4696 in 2014/15 to 4264 in 2016/17.
Overall, compared to other localities across TEWV, demand for mental health services is three times higher in the Harrogate area (this is based on numbers of referrals, adjusted to take into account the expected mental health needs of the population).
Over the last three years we have seen a reduction in the number of admissions (from 165 in 2014/15 to 131 in 2016/17) whilst lengths of stay have risen slightly (from 19 days in 2014/15 to 24 days in 2016/17). This has been assisted by the supportive work of crisis and home treatment in adult mental health services. In addition, the introduction of the personality disorder pathway has helped keep people at home. However, admission rates for adults in Harrogate are still higher than other areas of the Trust.
Why do we need to change?
Since responsibility for mental health and learning disability services transferred to TEWV in 2011 the Trust has been committed to replacing the inpatient accommodation at the Briary Wing in Harrogate. The building and environment is not fit for purpose (highlighted by the Care Quality Commission) and there is agreement that it needs replacing. The Briary Wing will likely remain on the Harrogate site until late 2019 at the earliest, but this will be reviewed from an environmental, staff and user/carer perspective, as well as clinical need, as the engagement work progresses.
Over the last few years we have talked with people who access mental health services, their carers, staff and the public to review the options for inpatient care. A plot of land was purchased at Cardale Park in Harrogate in 2016.
Increasingly people are able (and want) to receive the care and support they need at home. We need to make sure that we are making best use of our resources – that every pound spent on mental health services provides the best possible outcome for the people who access those services.
We know that health and social care services across the country are facing significant financial challenges. People are living longer and the demand for mental health services is rising.
We therefore need to review how all funding is spent, including this development, and consider carefully any longer term investments.
For example, the value of inpatient services is £4.6m (31.4%) of the total £14.5m spend on mental health in Harrogate. Proportionally, this is a large amount of money spend on a relatively small number of the total population of people experiencing mental health conditions.
We also know that some hospital admissions (particularly for older people) can lead to more risks and a decline in health including:
Increased risk of illness and death
Diminished quality of life
Less autonomy and greater dependence
Admittance to nursing and residential homes
Increased lengths of hospitalisation
Readmission to hospital
Whilst we recognise that inpatient care is at times a vital part of what keeps a person safe and well, we also acknowledge the risks that can arise from being in hospital. We want to ensure that we are doing all that we can to prevent inappropriate hospital admissions.
What should we consider?
We now have an opportunity to think about the overall model of care in Harrogate, and not just in-patients.
This may include considering whether more spent on community provision would provide an overall better service and reduce the need for people to have to spend time in hospital.
We can also think about how this is linked to our overall recovery approach - to supporting people to achieve the goals they've set themselves and to making sure people get the care and support they need, when and where they need it.
We will think about how we can:
- Embed recovery values and principles into all we do.
- Support a model of ‘co-production’
- Implement a harm minimisation approach to support an individual’s recovery, with people with lived experience and where appropriate, family members as partners and carers in the process.
- Increased access to recovery training which supports recovery knowledge and self-management skills for staff, people with lived experience, family members and carers.
We want to know:
- In the future, what would you like the mental health services in Harrogate to look like?
- Thinking about the strengths of the current Harrogate services, what are the three things you’d like to see remain in future services?
- Thinking about the things you’d like to see improved, what are the three priority issues you’d most like to fix?
- What are your thoughts on the future of inpatient beds for local adults and older people?
- Thinking about the needs of carers and families – what would you like to see available to better support the families and carers of people with mental health conditions?
- What type of community services would you like to see available to help keep you well?
- Is there enough emphasis on recovery, social inclusion, training and education and/or volunteering through to employment to support active citizenship? If not, what other services would you like to see?
How to get involved
What happens next?
We want to check that people feel these themes represent what they told us.
We want to continue to work with local people including service users, carers, staff and partner organisations to look at the possibilities in more detail and develop options for the future.
We are holding three public events:
Tuesday 6 March 2018
10am – 12 noon
Ripon Community House
Monday 19 March 2018
1 – 3pm
Chain Lane Community Hub
Tuesday 27 March 2018
10am – 12 noon
The Old Swan Hotel
It would be helpful if you could let us know if you intend coming along to one of the workshops. You can also continue to send us your views and suggestions to:
tewv.harrogateengagement@ nhs.net or FREEPOST TEWV.
Of if you would like to speak to someone please contact 01423 553681.
We look forward to hearing from you.